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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 203810223
Report Date: 11/15/2022
Date Signed: 11/15/2022 11:09:30 AM

Document Has Been Signed on 11/15/2022 11:09 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:MADISON STATE PRESCHOOLFACILITY NUMBER:
203810223
ADMINISTRATOR:NORA GUILLENFACILITY TYPE:
850
ADDRESS:109 STADIUM RDTELEPHONE:
(559) 675-4630
CITY:MADERASTATE: CAZIP CODE:
93637
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 15DATE:
11/15/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:RHIANA THORNTONTIME COMPLETED:
11:15 AM
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On 11/15/2022 Licensing Program Analyst (LPA), Stephanie Vega-Gonzalez conducted an unannounced case management inspection. LPA Vega-Gonzalez met with ECE Teacher Specialist, Rhiana Thornton. The Purpose of today's inspection is to conduct a Case Management Inspection regarding a lead exceedance referred to as an Action Level Exceedance (ALE) of over 5.5 parts per billion (ppb) in the water at this facility.

Fresno Regional Office received notification of water lead exceedance at the facility on 11/02/2022 resulting from a recent water lead sampling test that was conducted on 07/19/2022. Based on records reviewed from BSK Associates a Certified Laboratory and discussions with Rhiana Thornton it has been determined there is an exceedance to outlet labeled “A” on LIC 999 in the facility. LPA Vega-Gonzalez inspected outlet “A”, and it was observed to be an indoor sink with a water fountain, that was impacted with a test result of 11 ppb (ALE) of lead. Rhiana Thornton stated that the following actions had been taken,

During today’s inspection LPA observed that the usage of faucet water outlet "A" had been stopped. LPA noted that there is no running water on outlet “A”. Rhiana stated that the facility has collaborated with the District's Child Nutrition Department and they had provided the classrooms with portable water bottles to be used. The Child Nutrition Department has provided the facility with 45 cases for the classroom. Upon observation, LPA observed 4 cases of 24 bottles of 16oz during today’s inspection and a red 2-gallon Rubbermaid container filled with Crystal Geysers spring water bottles for outdoor area. Children have full access to outdoor water in Rubbermaid container and there are disposable cups for drinking. Rhiana Thornton stated that the classroom teachers will notify their site custodians when the classroom is running low and they will deliver those cases to their classrooms to ensure they have enough drinking water for children and staff in the classrooms and for outdoor activities. Rhiana stated that a notification was sent through the MUSD parent communication platform, Parent Square.

(Continue on LIC809-C)

SUPERVISORS NAME: Juvenal Moctezuma
LICENSING EVALUATOR NAME: Stephanie Vega-Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: MADISON STATE PRESCHOOL
FACILITY NUMBER: 203810223
VISIT DATE: 11/15/2022
NARRATIVE
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The notification informed parents of the ceasing use of drinking water from the faucets tested in the classrooms outlet "A", and the provision of water bottles provided by Child Nutrition. The notice also included the time frame for retesting and that they will be notified of the results. LPA obtained a copy of the parent notification. LPA reminded Rhiana that the posting of the parent notification and the test results need to be posted in a visible area for parents and guardians to view. Rhiana stated she understood.

Rhiana stated that outlet “A” will be retested by a certified external water sampler and that outlet “A” will not be used until it meets the allowable Action Levels of 5.0 ppb or until repairs can be made. In addition, LPA observed a Trio-water fountain in the outdoor play area that is functioning and accessible to children. LPA informed Rhiana that fountain will also need to be tested by a certified external water sampler. Rhiana stated she understands. (See Plan of Corrections for further corrective actions on LIC809-D). Rhiana Thornton has notified authorized representatives of this correction in (both languages English and Spanish).

Per Title 22, Division 12, Chapter 1, of the California Code of Regulations, a Type B deficiency is being cited: (see next page, LIC 809-D). Rhiana Thornton, was provided a copy of appeals rights. An exit interview was conducted with, Rhiana Thornton.

This report shall be made available to the public upon request.

LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

SUPERVISORS NAME: Juvenal Moctezuma
LICENSING EVALUATOR NAME: Stephanie Vega-Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/15/2022 11:09 AM - It Cannot Be Edited


Created By: Stephanie Vega-Gonzalez On 11/15/2022 at 10:40 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: MADISON STATE PRESCHOOL
FACILITY NUMBER: 203810223

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2022
Section Cited

101700.3

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101700.3 California Lead Action Level at Child Care Centers (a) California's Action Leve for lead in water at Child Care Centers is 5 ppb. (b) Testing results with fractional ppb readings of 0.5 ppb or greater shall be rounded up to the nearest whole number, before comparing to the Action Level. (1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance at any water outlet, the water from that outlet is deemed not safe to drink and an immediate response pursuant to section 101704 shall be required.
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Authorized representatives have been notified. Licensee has agreed to resample outlet “A” and get outdoor water fountains tested by a certified sampler. The facility has provided the following for the children in care: 45 cases of 24 bottles of 16oz a red 2-gallon Rubbermaid container filled with
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This requirement was not met evidenced by: Based on record review provided by BSK Associates a result of (ALE) of 11 ppb for outlet “A”. Which is out of compliance over the allowable AL 5 ppb. This poses a potential health, safety or personal rights risk to persons in care.
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 Crystal Geysers spring water bottles for outdoor area. Licensee will provide evidence of outlet testing at or below the Action Level of 5 ppb. Licensee will refer to PIN 21-21-CCP Release of the Written Directives for Lead Testing of Water in Licensed Child Care Centers Per AB 2370. Licensee's POC is due on 12/15/2022. Licensee will provided CCL with the required tests reports and documents.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Juvenal Moctezuma
LICENSING EVALUATOR NAME:Stephanie Vega-Gonzalez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2022


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